Healthier Prepared Food Environments: Using the Texas ......Improve the environment and practices of prepared food outlets. Identify health-promoting environmental and practice factors

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Healthier Prepared Food Environments: Using the Texas Nutrition Environment Assessment in Restaurants (TxNEA-R) Tool in Your Community

October 2016

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Table of Contents

Purpose ......................................................................................................................................................... 3

Definitions ..................................................................................................................................................... 3

About the TxNEA-R Tool ............................................................................................................................... 4

Tool Components ...................................................................................................................................... 4

Tool Psychometrics ................................................................................................................................... 4

Possible Interventions in Prepared Food Outlets ......................................................................................... 5

Sample Timeline for a Community TxNEA-R Assessment ............................................................................. 5

Protocols ....................................................................................................................................................... 6

Project Coordinator Protocols .................................................................................................................. 6

Preparation ........................................................................................................................................... 6

Field Work ............................................................................................................................................. 9

Planning, Implementing, Evaluating, and Sustaining Strategies ........................................................... 9

Rater Protocols........................................................................................................................................ 11

Preparation ......................................................................................................................................... 11

Field Work ........................................................................................................................................... 11

Logic Model ................................................................................................................................................. 13

References .................................................................................................................................................. 14

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Purpose

In order to implement strategies to improve the environment of food outlets in your community, it is important to assess the prepared foods environment. The purpose of this manual is to describe the logic, background, and protocols for Texas Department of State Health Services (DSHS) staff and Texas communities to successfully use the Texas Nutrition Environment Assessment in Restaurants (TxNEA-R) tool.

Note: An asterisk (*) on a protocol indicates that the protocol is in coordination with another role and more information is available on the protocols for the other role.

Definitions

Project coordinator: a community representative who oversees the community assessment and manages raters.

Community stakeholder: any organization or group that is interested in improving the nutritional environment and practices of prepared food outlets or increasing the reach of prepared food outlets with healthy environments and practices.

DSHS coordinator: DSHS staff who oversees and provides technical assistance to project coordinators and updates the TxNEA-R material as needed.

Face/construct validity: the degree to which a tool appears to measure what it claims to measure.

Inter-rater reliability: a measure of whether different raters would provide similar responses for the same survey items.

Prepared food outlet: a food service establishment that sells prepared, ready-to-eat food. Types of prepared food outlets include table-service restaurants, fast-food restaurants, take-away, in-store food outlets.

o Table service: an establishment where the customer is served by wait staff. This may include a restaurant inside of a hotel.

o Fast Food/Fast Casual: an establishment that has tables inside but does not have formal table service, or has only limited service of items like drinks and condiments. This category includes buffets.

o Take-away: an establishment where, for the majority of customers, food is not eaten inside the store, but is taken elsewhere for later consumption. It has no table service, but may have a very limited seating inside or outside the premises. This category includes food trucks.

o In-store: an establishment where foods are prepared within another store whose primary purpose is not food service, such as a grocery store, convenience store, or big-box store. Food outlets that do not sell foods prepared on the premises are not included.

Rater: a community member who meets with managers and collects data from prepared food outlets to assess the nutrition environment.

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About the TxNEA-R Tool The TxNEA-R tool can be used in prepared food outlets, such as, restaurants with table service; fast food or fast casual restaurants with no or minimal table service; take-way, such as a food truck, food stand, or carry out or drive through only where a few chairs are available; and in-store settings where prepared foods are sold inside of another setting such as a grocery store, super store, or gas station. The TxNEA-R tool is not useful for specialty shops where meals are not sold, such as bakeries or smoothie shops.

Communities can use the TxNEA-R tool to assess the nutrition environment of prepared food outlets in order to:

Improve the environment and practices of prepared food outlets.

Identify health-promoting environmental and practice factors of prepared food outlets

Increase the reach of prepared food outlets with healthy environments and practices.

TxNEA-R measures the following constructs:

Availability of healthier and less healthy foods and beverages

Barriers to making healthy choices

Facilitators of making healthy choices

The TxNEA-R tool and supporting resources can be found at http://www.dshs.texas.gov/Obesity/TXNEAR/.

Tool Components The components of the TxNEA-R tool are the survey, instructions, and glossary. The TxNEA-R tool is available in an electronic version and a paper version. The electronic version of the tool is available on Survey Monkey, an online survey software platform. All tool components can be found at the URL on the title slide. In this version, the survey, instructions, and glossary are included in the question. The online tool can be accessed on a computer or a smart device. A practice version of the TxNEA-R tool is available on Survey Monkey; data entered into the practice copy will not be included in the assessment. After becoming comfortable with the tool using the practice copy, raters should use the actual survey.

In the paper version of the tool, the survey, instructions, and glossary are separate documents. After collecting the data using the paper document, the data must be entered on Survey Monkey. The paper version of the survey is more useful for larger food outlets with larger, more complicated menus that require more time. When using the paper version of the tool, raters are able to skip to different areas of the survey.

Tool Psychometrics

The TxNEA-R tool is valid and reliable and has the following characteristics:

• Inter-rater reliability

– Substantial agreement ranging from 62% to 96%, with mean percent agreement of 79%1

• Face/Construct validity

– Dietary Guidelines for Americans 2015-20202

– RAND Performance Standards for Restaurants3

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– Reviewed by relevant subject matter experts

Possible Interventions in Prepared Food Outlets An assessment of the prepared food environment using the TxNEA-R tool can facilitate the following types of actions:

• Increase availability of healthier foods and beverages

• Decrease availability of less healthy foods and beverages

• Increase facilitators to healthy choices

• Remove barriers to healthy choices, and

• Promote food outlets with a healthy environment

Sample Timeline for a Community TxNEA-R Assessment This timeline suggests an approximate time period to complete a community assessment in order to

inform planning. It does not include the time for interventions.

Preparation

(1-3 months)

•Project coordinator determines objectives with stakeholders and determines sampling of food outlets.

•Project coordinator and raters complete trainings.

•Project coordinator reviews Manual of Procedures.

•Raters practice using the tool (1-2 weeks).

Assessment (1-3 months)

•Raters meet with food outlet managers to inform them on the project and ask for consent for the assessment.

•Raters assess food outlets where the manager has consented.

•Data is entered into the online system.

•DSHS provides results of the assessment.

Communication and Action Planning (1-3

months)

•Communities review assessment results and conduct additional analyses, if needed.

•Communities share assessment results and discuss possible strategies with partners.

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Protocols

Project Coordinator Protocols

Preparation

1. Community representatives interested in the TxNEA-R tool complete the online Tool

Background training to determine if the TxNEA-R tool is in line with their organization’s goals,

capacity, and readiness.

a. The Background Training includes information on what the tool measures, what kinds

of actions can be taken, resources (personnel and time) needed, the detailed nature of

the project, necessary partners, and limitations of the tool.

2. A community representative who decides to use the TxNEA-R tool and leads the project

becomes the project coordinator. The next step is to review the survey, instructions, and

glossary to become more familiar with the tool.

3. Review the survey, instructions, and glossary.

4. Review the “Effective Strategies for Making Healthy Choices Easier When Eating Out” webpage

and one-pager and the “TxNEA-R Strategies” to get ideas for strategies to implement in

prepared food outlets. These are on the http://www.dshs.texas.gov/Obesity/TXNEAR/ page.

5. Consult with stakeholders and identify objectives.

a. Contact stakeholders of a restaurant environmental intervention and engage them in

the assessment and planning process. For example, if a community’s objective is to

recognize food outlets with healthy environments or policies, the stakeholders could be

a coalition whose mission is to promote healthy eating, such as a restaurant association

or an association of nutrition educators in the community who may refer their patients

to the food outlets. Other examples of stakeholders could be policy makers, nonprofit

and public health organizations working on chronic disease prevention, local residents,

and healthcare administration or professionals.

b. The project coordinator may conduct a stakeholder analysis to identify stakeholders to

include in the project. Stakeholder analysis tools, such as MindTools4, can be found

online.

c. When recruiting stakeholders, describe any health outcome(s) of interest and the role of

food outlets in influencing behavior. Describe strengths, limitations, and possible

interventions of the tool to interested stakeholders. Describe the resources needed to

complete the assessment. Ask stakeholders if they are interested and if so, what role

they would want to have in the assessment or intervention. After recruiting a suitable

stakeholder, decide on a method of communication.

d. Outline goals and objectives. An intervention could be decided at this point which would

focus the assessment.

6. * Contact DSHS to receive a link to your online survey.

a. Contact DSHS at [email protected] to express your interest in using

the TxNEA-R tool. Provide your contact information, a description of your project

objectives, and the geographic area of your assessment. DSHS will use this information

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to confirm that the community’s objectives are a good match with the TxNEA-R tool and

send a link to a survey for your project where data will be entered

7. Complete Project coordinator Training and review the TxNEA-R Manual.

a. The training and manual describe the protocols necessary in the preparation and

implementation of the TxNEA-R assessment and provides information on how to use the

results.

8. Complete the Rater Protocol Training and Data Collection Training and pass the data collection

quiz.

a. The primary audience for these trainings is the raters. The secondary audience is the

project coordinators. The Rater Protocol Training consists of protocols to approach food

outlet managers and conduct the assessment. The Data Collection Training outlines the

instructions for using the tool and includes practice exercises. Coordinators need to

know this information in order to help raters with any questions and fully understand

the features of the assessment tool.

9. Follow local and federal policies related to data collection and those related to privacy and

research when applicable.

a. The TxNEA-R tool cannot be used to collect information on human subjects, so it is

exempt from Institutional Review Board (IRB) review.

10. Decide on which prepared food outlets to assess.

a. Decide on a geographic area of interest for your intervention and assessment. This

represents the target area where you will try to make changes to the environment of

prepared food outlets. This may be a county, city, metropolitan statistical area (MSA),

neighborhood, census tract, or zip code. You may choose to target areas with high

prevalence of chronic disease, food swamps (areas with an abundance of less healthy

food options), areas of high population density, or areas where people at highest risk of

chronic disease live and work.

b. Project coordinators may contact [email protected] to request

maps which display patterns of disease, population density, food access or other factors

in your geographic area. For example, access to healthy food retailers can be

determined based on the modified retail food environment index (mRFEI)5. In your

request, be specific about which data to map, specify the geographic area, and provide

your contact information. Allow at least 3 weeks to receive the map(s).

c. Decide on which prepared food outlets to assess in your geographic area. Try to include

more local food outlets in your sample where the decisions and changes can be made

locally. The decisions for large national chains are made at the corporate level, and local

change is hard to make. Based on your project’s objectives and resources, decide on and

implement a sampling method for food outlets in your community.

d. Make a list of food outlets in the final sample and assign each of them a 3-digit Survey

Number, which will be used to track progress at the food outlet and entered at the

beginning of each TxNEA-R survey.

11. Optional: Some coordinators may prefer training data collectors themselves. If you prefer to

train data collectors yourself instead of having them complete the online training, email

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[email protected] to request copies of the presentations. Familiarize

yourself with the content.

12. Optional: Locate or develop materials to inform food outlet managers about the project.

a. Locate or develop materials on the project, the health outcome, the health behavior,

and the role of food outlet managers to help raters gain the consent of food managers

to participate in the project.

b. Include recent data on these materials to describe the prevalence of nutrition-related

chronic diseases. Use data to describe the demand for healthy options or the role of

healthy options in a good business model.

i. Do not blame food outlet managers for adverse health outcomes related to

eating out. Emphasize how they could support healthy choices for children and

adults in the community and how this could improve their business.

1. Use plain language and visuals to support your message.

2. Provide accommodations for accessibility as needed.

13. Determine the number of raters necessary for the project and recruit raters, if needed.

a. Based on your timeline, the number of prepared food outlets you plan to assess, and

the capacity of raters, determine the number of raters needed. See rater protocols for a

description. A recommended practice is to pair two raters to engage food outlet

managers and complete the assessment. Recruit an appropriate number of raters as

needed.

b. It is recommended to work with raters with whom you have a strong relationship and

who are detail-oriented and/or knowledgeable in nutrition. Students of public health or

nutrition may be a good choice.

14. * Direct raters to complete the online training and train them on the materials for the food

outlet managers if needed. Confirm that raters have successfully completed the Rater Protocol

Training and Data Collection Training and piloted the tool.

a. Raters must pass the quiz at the end of the Data Collection Training, practice the survey

at a food outlet outside of the sample, and follow up with the project coordinator.

b. This is to ensure that the tool is being used correctly and to make sure if the raters are

comfortable with the tool when discussing the project with food outlet managers and

while conducting assessments.

15. * Provide raters with a link to the online survey and their Rater ID and record the information on

the Rater Form. This information is needed to complete the practice survey.

16. * Debrief with raters on how their assessment went.

a. Raters should notify the coordinator when they have completed one practice survey at a

prepared food outlet.

17. * Assign food outlets and survey numbers to raters and direct raters to begin engaging food

outlet managers. After the rater confirms that he/she has practiced the tool, send a list of

survey numbers and the restaurant information to the rater.

a. Assign food outlets with survey numbers. Assign survey numbers to raters and note the

assignments on The Coordinator Tracking Tool. You may want to assign groups of

restaurants that are close together to one rater or pair of raters to be considerate of

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their time and resources. Be considerate of travel distance for volunteers whose

mileage is not paid. Based on the capacity of raters, assign 1 or 2 raters to each food

outlet. It may be better to send raters in pairs. Let pairs know which rater they are

paired with and the other rater’s contact information.

b. Raters may need to contact the prepared food outlet more than once to get in contact

with the manager. After they get in contact, raters may need to meet with a food outlet

manager more than once to explain the project and gain the manager’s consent.

Establishing a good relationship with food service managers is important because they

must agree to participate in the project and be open to suggestions in order to access

the food establishment.

Field Work

18. * Raters inform restaurant owners and managers about the project and gain consent and

cooperation to participate. Communicate regularly with raters.

19. * Work with raters to complete data collection and assist raters as needed. Receive The Rater

Form from raters when they have completed data collection and confirm that all surveys are

complete. Contact DSHS for technical assistance.

Planning, Implementing, Evaluating, and Sustaining Strategies

20. * Request your assessment results.

a. Contact [email protected] to ask for the results of your assessment.

DSHS will send the assessment results, raw data, and practice opportunities.

i. The assessment results report lists the results for each prepared food outlet and

for all the food outlets aggregated.

ii. The practice opportunities describe options of interventions to improve the

prepared food environment which have occurred in restaurants. It also

describes the effectiveness of these interventions and links to implementation

tools.

iii. The raw data can be used to conduct additional analyses if needed.

21. Review assessment results and practice opportunities. Conduct additional data analysis if

needed.

a. Review assessment results and practice opportunities within your organization. You may

wish to share the aggregated results with volunteer raters.

i. To conduct additional data analysis, use the raw data and data dictionary.

22. Share assessment results with stakeholders.

a. Share results of the assessment and practice implications with stakeholders and

community members and engage them in creating an action plan.

i. The community project coordinator, leaders, or community members may

communicate the results.

ii. Some examples of ways to communicate include a presentation at a coalition

meeting or other meeting, discussion, one-pager, webinar, Twitter, Facebook

post, blog post, email, abstract, journal article, or a written report posted

online. Methods of communication depend on the community’s objectives.

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23. Plan, implement, and evaluate the intervention. Create and implement action plan with

stakeholders. Evaluate the intervention.

a. * Create your action plan with your stakeholders. Include SMART (Specific, Measurable,

Attainable, Realistic, Time-bound) objectives, a timeline, roles, plans for sustainability,

and budget information in the action plan.

i. You may want to create a logic model for your intervention based on the logic

model at the end of this Manual. The process of creating a plan with

stakeholders helps obtain their buy-in. The plan may help prepare to apply for

funding or if funding is already secured, to launch into implementing an

intervention. Share the action plan with DSHS.

b. Implement and evaluate the intervention. An evaluator may be involved to ensure that

a piloted intervention is evaluated correctly and that appropriate data are being

collected to inform the evaluation.

24. If the results of the evaluation are favorable, create a sustainability plan.

a. Collaborate with stakeholders to create a sustainability plan. Effective interventions

need to be sustainable and interventions in food outlets often need outside support

from a health organization. A need for support from a health organization arises in

circumstances, such as when restaurants tend to have high turnover and need periodic

training for new and old staff on protocols for the intervention in order to maintain

reliability.

i. One way to help this is to use a “train the trainer” method and train the owner

or manager, who will then train the staff. Your organization may periodically

check in with the owner or manager to see if they need a refresher or are still

implementing the intervention.

1. One resource is the Program Sustainability Assessment Tool 6, which

assesses the sustainable capacity of a program across a range of factors.

2. A way to ensure sustainability is to institutionalize the intervention by

adding activities that maintain the intervention to job descriptions.

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Rater Protocols

Preparation

1. * Optional: Complete Background Training.

a. A recommended practice is to complete the online Background Training that is required

for the project coordinator.

i. This will help raters understand the tool’s purpose and what types of

interventions can result. It can also help raters to better present the project to

food outlet managers and answer their questions.

2. * Complete online Rater Protocol Training, Data Collection Training and pass quiz at the end.

a. The online Rater Protocol Training describes the protocols for approaching food outlet

managers and gaining their agreement in working on improving the environment of

their food outlet and collecting data using the tool.

i. The Data Collection Training describes the survey questions, instructions, and

definitions and includes practice exercises.

b. Complete the data collection quiz after completing the Rater Protocol and Data

Collection trainings.

3. * Receive Rater ID and link to the online survey (optional) from project coordinator.

a. The Rater ID helps the project coordinator keep track of who filled out which surveys, in

case any questions arise later.

b. Data from the assessment can be entered at the link to the survey. Your coordinator

may ask you to complete the survey or complete it themselves. project coordinator

c. Using the paper copy of the tool, choose a prepared food outlet and conduct the

assessment. Practice using the protocols for data collection. Practice using The TxNEA-R

Rater Form and the protocols. Explain to the food outlet manager that you are

practicing the tool and ask for their permission to proceed. Use the practice version of

the tool. Explain that the data from the assessment will not be used.

d. Try to choose a food outlet with a children’s menu so that the entire survey is shown. If

there is no children’s menu, the rater will not be able to practice this part of the

assessment.

4. * Receive a list of prepared food outlets and corresponding survey numbers from the project

coordinator. The Survey Number is entered at the beginning of each survey.

5. Prepare for work in the field.

a. Complete Table 1 in The TxNEA-R Rater Form using the survey numbers. If you are

paired with another rater, exchange contact information and coordinate schedules with

them. Complete the checklist on The TxNEA-R Rater Form.

Field Work

6. Meet with food outlet owners/managers to inform them about the project and gain consent and

cooperation to participate.

a. Building trust and a positive working relationship with food outlet managers is

important to gain their participation in the intervention.

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b. Approach the foodservice manager in a professional manner. It may take 1-3 attempts

of contacting the food outlet before reaching the manager. Explain which

organization(s) you are with, the objectives of the project, and how this could benefit

the manager’s business. Ask if they would be willing to take a few minutes to hear more

about the project. Repeated visits may be needed to gain the manager’s consent. If your

project coordinator has provided information for the managers, offer to present it to

them.

i. If the manager is not interested, offer to leave the information for them to look

over and your contact information, and thank them for their time.

7. Data collection

a. Use the survey, instructions, and glossary to complete assessments of food outlets

where you have gained manager consent.

b. If using the paper tool, enter the data into Survey Monkey.

c. Ask the food outlet staff questions as needed.

8. * Communicate regularly with your project coordinator about the status of your assigned food

outlets.

9. * Complete Table 2 in The TxNEA-R Rater Form and send Form 2 to the project coordinator

when surveys have been entered.

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Logic Model

Resources Activities Outputs Indicators Outcomes Impact

Personnel ready and able to conduct the assessment:

DSHS Coordinator and Staff

Project coordinator

Raters

Community Stakeholders

Materials:

TxNEA-R Tool

Trainings

Manual and forms

Information packets for food outlet managers

Funds necessary for the assessment

DSHS :

Promotes the tool

Provides assessment results and practice recommendations

Provides technical assistance as needed.

Monitors implementation of project.

Project coordinator:

Completes Background Training and determines if the tool is a good fit

Identifies stakeholders.

Identifies and prioritizes community objectives.

Completes all trainings.

Identifies geographic unit and sample of the foodoutlets

Recruits raters.

Interprets assessment results.

Facilitates action planning with stakeholders.

Raters:

Gain consent of food outlet managers.

Complete data collection.

DD

Promotion of TxNEA-R tool

Utilization of TxNEA-R resources on DSHS site

Identified stakeholders

Community Objectives

Completion of trainings

Samples of prepared food outlets

Consent from food outlet managers

Assessment results

Identification of practice opportunities

Communication of assessment results

Community action plans

# Promotions of tool

# Community representatives who receive promotions

# DSHS TxNEA-R website visits

# Stakeholders

# Community objectives

# project coordinators and raters who take online trainings and pass quiz

# samples of prepared food outlets

# of managers who consent

# Surveys entered in online system

# Reports provided to communities

# Action plans

Short-Term:

↓ Availability of less healthy foods and beverages

↑ Availability of healthier foods and beverages

↓ Barriers to choosing healthy foods and beverages

↑ Facilitators to choosing healthy foods and beverages

↑ Promotions for healthy choices in food outlets

Long-Term:

↓ Consumption of less healthy foods and beverages

↑ Consumption of healthier foods and beverages

↓Prevalence of overweight and obesity

↓Prevalence of diabetes

↓Prevalence of hypertension

↓Prevalence of cardiovascular disease

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References

1. Field testing a nutrition environment assessment tool for food outlets in rural Texas. www.isbnpa.org/files/annual_meetings/2014/10/13/15/attachments/543c3fbedc145.pdf

2. Dietary Guidelines for Americans. https://health.gov/dietaryguidelines/2015/guidelines/ 3. RAND Performance Standards for Restaurants.

www.rand.org/pubs/conf_proceedings/CF313.html 4. MindTools Stakeholder Analysis. www.mindtools.com/pages/article/newPPM_07.htm 5. CDC mRFEI document. ftp.cdc.gov/pub/Publications/dnpao/census-tract-level-state-maps-

mrfei_TAG508.pdf. 6. Program Sustainability Assessment Tool. sustaintool.org/